Dr. Diane Hediger - Secure Client Area

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Terms and Policy

Policies and Service Agreement

Welcome to my practice. I appreciate your giving me the
opportunity to be of help to you. This form provides you with
information that you need in order to make an informed choice
regarding your therapy. If you have any questions please do not
hesitate to ask and I will address them during your intake
appointment.

Therapy Process

To provide you with the best possible care, it is important that
I have a clear understanding of what brings you to treatment. To
assist me in this process, I will ask you to complete several
forms. During our initial meetings I will also ask you detailed
questions about your current and past functioning, including
family and work history, past mental health problems, previous
treatment, history of abuse or trauma and drug and alcohol use.
Based on this information we will develop goals and an agreed
upon treatment plan. This treatment plan will dictate the
approach we will take, the frequency, and duration of treatment.
During this period, I will determine if I can be of benefit to
you. I do not accept clients who I believe I cannot help. In such
a case, I will give you a number of referrals that you can
contact.

Participation in therapy can result in a number of benefits to
you, including improved coping skills, improved interpersonal
relationships, and resolution of the specific concerns that led
you to seek therapy. Your personal goals and values may become
clearer and you may grow in your ability to enjoy life more
fully. Working towards these benefits however requires effort on
your part. Psychotherapy requires your active involvement,
honesty, and openness in order to change your thoughts, feelings,
and behaviors. An important part of your therapy will be
practicing new skills that you will learn in our sessions. Change
will sometimes be quick and easy, but more often it will be slow
and frustrating, and you will need to keep trying. My goal is to
help and support you through these changes and I encourage
feedback or concerns you may have about any aspect of the
process. If at anytime you feel misunderstood, have doubts about
the effectiveness of your treatment, or believe that treatment is
misguided, it is important that you bring this to my attention.
Open communication and feedback need to occur throughout
treatment and I will periodically ask you for input. During
therapy, remembering, or talking about unpleasant events,
feelings or thoughts can result in uncomfortable levels of
sadness, anxiety, anger, frustration, loneliness, fear, or other
negative feelings. Problems may even temporarily worsen after
beginning of treatment but this is to be expected as you make
important changes in your life and should subside as the therapy
progresses. However, attempting to resolve issues that brought
you to therapy in the first place, such as personal or
interpersonal relationships, may result in changes that were not
originally intended. Finally, despite even our best efforts,
there is the possibility that therapy may not work out well for
you. During the course of therapy, I am likely to draw on various
psychological approaches according, in part, to the problem that
is being treated and my assessment of what will best benefit you.
These approaches include cognitive-behavioral, family systems,
mindfulness, and relaxation, interpersonal, developmental, or
psycho-educational.

Telehealth Services

Telehealth is the remote delivery of clinical information and
health care service using telecommunications technology. This
information and services may include client medical records, live
two-way audio and video conferencing, and instant messaging.
Telehealth is a significant and rapidly growing component of
health care. Worldwide millions of individuals use telehealth as
part of their care and an increasing number of consumers download
health and wellness applications for use on their mobile
phones. According to the American Telemedicine Association,
telehealth has been backed by decades of research and
demonstrations and has been found to be a safe and cost-effective
way to extend the delivery of health care. The benefits of
telehealth include:

- improved access to healthcare
by bringing healthcare services to individuals in distant and
remote locations and allowing
healthcare providers to expand
their reach.

- reduced healthcare costs.

- improved quality as shown by
numerous studies indicating that services delivered via
telehealth are as good, if not superior,
to traditional in-person services
particularly with regard to mental health care where better
outcomes and client satisfaction
are reported.

-Increased consumer demand
since using telehealth reduces travel time and related stresses
for the individual as well as
offering access to providers
that might not otherwise be available.

Although rare, there are potential risks associated with the use
of telehealth. Possible risks may include: despite reasonable
efforts on my part, the transmission of sensitive information
could be disrupted or distorted by technical failures (e.g. poor
resolution of images); the transmission of sensitive information
could be interrupted or accessed by unauthorized persons; and/or
the electronic storage of sensitive information could be accessed
by unauthorized persons.In addition, the telethealth modality may
not be appropriate for everyone. I will tell you if I believe you
would be better served by face-to-face services and will refer
you to a practitioner in your geographical area who can provide
such services, if necessary. Since I do not provide
emergency or crisis services within my practice, and will refer
you to the appropriate services if it seems that distance support
through telehealth, is not clinically appropriate for you at this
time. I contract with several HIPAA compliant video platforms and
use practice management software. The service I use requires you
to register and login through the secure client portal via my
webpage. This allows us to communicate through safe and secure
written messaging, video, and instant message sessions while
keeping sensitive information protected. All of my client records
are stored securely online to ensure your privacy and I am the
only one who has access to your encrypted information. The online
services I use to communicate, conduct videoconferencing and chat
sessions, and store records each utilize state of the art
HIPAA-compliant security. You are responsible for information
security on your computer or device. If you decide to keep copies
of our confidential clinical correspondence on your computer or
device, it is your responsibility to keep that information
secure. I ask that you determine who has access to your computer
and electronic information prior to our sessions. This would
include family members, co-workers, supervisors, and friends. I
encourage you to only communicate through a computer that you
know is safe, i.e. wherein confidentiality can be ensured. Be
sure to fully exit all online telehealth sessions. I encourage
you to find a location for our sessions with proper lighting,
limited audio and visual distractions, and a sound barrier to
prevent others overhearing the session. There is the possibility
of an interruption in service due to technical difficulties or
poor visual quality. In the event that this happens, I will
re-initiate the session. If reconnection is not possible, please
have available the telephone you listed as your primary contact
so that I can call you during that time. Please be aware that I
cannot be held responsible for disruptions or interruptions to
our communications.

Termination

If at any point during treatment, I assess that I am not
effective in helping you reach your therapeutic goals or if
another form of therapy, that I cannot provide, is indicated, I
will discuss this with you and, if appropriate, terminate
treatment. In such a case, I will give you a number of referrals
that may be of help to you. You have the right to terminate
therapy at any time. If you would like to stop therapy, I ask
that you agree to attend at least one session to discuss our work
together, review your progress, and close our relationship in a
healthy way. If more that 30 days have passed since our last
contact, and I have not received any communication from you, I
will accept this as your notice that you no longer wish to
continue treatment and that our therapeutic relationship is
terminated.

Confidentiality and Exceptions

All information, disclosed within sessions and the written
records pertaining to those sessions, is confidential and may not
be revealed to anyone without your written permission, except
where disclosure is required or permitted by law. If you would
like me to share information or records, you will need to sign a
release of information form. In couple and family therapy, or
when different family members are seen individually,
confidentiality and privilege do not apply between the couple or
among family members. Dr. Hediger will use her clinical judgment
when revealing such information. Records will not be released to
any outside party unless authorization is obtained from all adult
family members who were part of the treatment. In cases of
divorce or separation, both parents must give consent for
treatment of their child as well as authorize any release of
information. If you are planning on using your insurance to pay
for therapy, I will disclose a diagnosis for your treatment. If
the insurer asks for further information, I will discuss this
with you prior to disclosing any information. On occasion, I may
consult with other professionals about concerns or the course of
treatment, however, your identity will always be kept
confidential, and any identifying information will be changed.
What follows are some exceptions in which your privacy cannot be
kept confidential (for more details see also Notice of Privacy
Practices form).

When Disclosure Is Required By Law: Some of the
circumstances where disclosure is required by the law are: when
there is a reasonable suspicion of child, dependent or elder
abuse or neglect; and when a client presents a danger to self, to
others, to property, or is gravely disabled.

When Disclosure May Be Required: Disclosure may be
required as the result of a legal proceeding by or against you.
If I am subpoenaed or court ordered to testify, I may have to
give information about you without your permission. If this does
happen, I will make every attempt to contact you.

Legal Proceedings

Psychotherapy is for the improvement of your psychological
functioning and is not intended to be used for the purposes of
current or future legal proceedings (e.g. custody, divorce, civil
proceedings, etc). My goal is to support my clients to achieve
therapy goals and not to address legal issues that require an
adversarial approach. It is important for you to know that I will
not be a party to any legal proceedings against current or former
clients. It is agreed that if there are legal proceedings (such
as, but not limited to divorce and custody disputes, injuries,
lawsuits, etc.), neither you (client) nor your attorney, nor
anyone else acting on your behalf will call on Dr. Hediger to
testify in court or at any other proceeding, nor will a
disclosure of the psychotherapy records be requested.

Email, Text Messaging and Social Media

It is important to be aware that e-mail correspondence and text
messaging are not considered confidential mediums of
communication. Communication through theses mediums should be
limited to non-sensitive correspondence such as appointment
scheduling, billing, and reminders. I will not respond to
clinical concerns via regular email. If you would like to send
personal or clinical information please do so via the secure
client web portal on my website at www.dianehedigerphd.com. I
will not engage in a social relationship on any social media
site. This is based on a concern for the potential loss of
privacy and blurring of the therapeutic relationship.

Contact and Emergency Procedures

If you need to contact me between sessions, please either leave
me a voicemail at (541) 556-8332 or message me via the secure
client web portal on my website at www.dianehedigerphd.com. I
check messages daily and will get back with you as soon as
possible. In the instance, I will be unavailable for an extended
period of time I will provide you with a referral in advance. Due
to the nature of my practice, I am unable to provide emergency
services. If, however, you have an urgent matter and cannot wait
for a response, you should contact the SAMHSA's National Helpline
at (800) 662-HELP (4357) serving individuals and family members
facing mental and/or substance use disorders or the National
Suicide Prevention Lifeline at (800) 273-TALK (8255). If you or
someone else is in imminent danger of harm, then you are
instructed to call 911 and/or go to your nearest emergency room.

Appointments and Cancellations

Sessions are scheduled for 55 minutes. The first appointment can
last up to 60-75 minutes in order to gather all the necessary
information. Sessions are usually scheduled weekly but could
occur more or less frequently depending on the needs of your
particular situation. If I am ever unable to start on time, I ask
your understanding. I assure you that you will receive the full
time agreed to or you will be charged only for the time used. If
you are unable to keep a scheduled appointment, please let me
know as far in advance as possible to reschedule. Failure to give
a 24-hour advance notice of cancellation may result in a $50.00
charge for the session. Please note that insurance companies will
not pay for missed or canceled sessions.

Fees, Payments, and Billing

My fees are $250 for an initial assessment and $200 for
subsequent sessions unless otherwise contracted with your
insurance provider. Payment is due at the time of service.
Additional professional services, including telephone
conversations lasting longer than 15 minutes, letter and report
writing, consultation with other professionals, longer sessions,
preparation of records or treatment summaries, and time spent
performing any other service you may request of me will be
charged at the same rate unless otherwise indicated and agreed.
If you choose to use your health insurance coverage, as a
courtesy service, I will submit claim forms on your behalf and
provide whatever reasonable information your insurance company
requests but I cannot guarantee that they will pay. Insurance
companies and policies vary in the amount of coverage,
deductibles, and co-payments and it is your responsibility to
verify the specifics of your coverage. Insurance companies may
not cover all issues and conditions which are the focus of
psychotherapy and may consider some services outside of the
benefit provided and as a result elect not to pay for them (e.g.
telephone consultations, preparation of letters and reports,
missed appointments, etc.). Be advised that you (not your
insurance company) are responsible for full payment if your
insurance company rejects a claim or pays it in part. Disclosure
of confidential information may be required by your health
insurance carrier in order to process claims and many insurance
companies require you to authorize me to provide them with a
clinical diagnosis. On occasion, I may need to provide additional
clinical information such as a treatment plan or copies of the
record. I assure you that I will share only the minimum necessary
to secure payment. Failure to pay fees may result in
discontinuation of treatment. If there is any problem with my
charges, my billing, your insurance, or any other money-related
point, please bring it to my attention and I will do the same
with you. Such problems can interfere greatly with our work and
they must be worked out openly.

Complaints

If you are unhappy with what is happening in therapy, I hope you
will talk with me about it so that I can respond to your
concerns. I take such issues seriously, and with care and
respect. If you believe that I've been unwilling to listen and
respond, or that I have behaved unethically, you may file a
complaint to either: the Oregon Board of Psychology Examiners,
Salem, Oregon 97302, www.Oregon.Gov/obpe, or the Arizona Board of
Psychologist Examiners, Phoenix, Arizona 85007,
https://psychboard.az.gov. You are also free to discuss your
complaints about me with anyone you wish, and do not have any
responsibility to maintain confidentiality, since you are the
person who has the right to decide what you want kept
confidential.

Electronic Signature of Client or Legal Guardian( Type Full Name )I have read and I agree to the Policies and Service Agreement

Notice of Privacy Practices

Notice of Psychologists' Policies and Practices to Protect
the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I may use or disclose your protected health
information (PHI), for treatment, payment, and
health care operations purposes with your consent. To
help clarify these terms, here are some definitions:

PHI: includes any
individually identifiable health information received or created
by my office or me.

Health information:
is information in any form that relates to any past, present, or
future health of an individual.

Treatment, Payment and
Health Care Operations:

- Treatment
is when I provide, coordinate or manage your health care and
other services related to your health care. An
example of treatment would be when I consult with another
health care provider, such as your family physician or another
psychologist.

- Payment is
when I obtain reimbursement for your healthcare. Examples of
payment are when I disclose your PHI to your
health insurer to
obtain reimbursement for your health care or to determine
eligibility or coverage.

- Health Care
Operations are activities that relate to the performance and
operation of my practice. Examples of health care
are quality
assessment and improvement activities, business-related matters
such as audits and administrative
services, and case management and care
coordination.

Use:applies only to
activities within my office such as sharing, employing, applying,
utilizing, examining, and analyzing
information that
identifies you.

Disclosure:
applies to activities outside of my office such as releasing,
transferring, or providing access to information about you
to other parties.

I may use or disclose PHI for purposes outside of treatment,
payment, and health care operations when your appropriate
authorization is obtained. I may use or disclose confidential
information (including but not limited to PHI) for purposes of
treatment, payment, and healthcare operations when your written
informed consent is obtained. I may use or disclose PHI for
purposes outside of treatment, payment, and healthcare operations
when your appropriate written authorization is obtained. An
authorization is written permission above and beyond the
general consent that permits only specific disclosures. In those
instances when I am asked for information for purposes outside of
treatment, payment and health care operations, I will obtain an
authorization from you before releasing this information. I will
also need to obtain an authorization before releasing your
psychotherapy notes. Psychotherapy notes are notes I have
made about our conversation during a private, group, joint, or
family counseling session, which I have kept separate from the
rest of your medical record. These notes are given a greater
degree of protection than PHI. I will also obtain an
authorization from you before using or disclosing PHI in a way
that is not described in this Notice.

You may revoke all such authorizations (of PHI or psychotherapy
notes) at any time, provided each revocation is in writing. You
may not revoke an authorization to the extent that:

(1) I have relied on that authorization.

(2) If the authorization was obtained as a
condition of obtaining insurance coverage, and the law provides
the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor
Authorization

I may use or disclose PHI without your consent or authorization
in the following circumstances:

Child Abuse: If I
have reasonable cause to believe that a child with whom I have
had contact has been abused I may be required to report the
abuse. Additionally, if I have reasonable cause to believe that
an adult with whom I have had contact has abused a child, I may
be required to report the abuse. In any child abuse
investigation, I may be compelled to turn over PHI. Regardless of
whether I am required to disclose PHI or to release documents, I
also have an ethical obligation to prevent harm to my patients
and others. I will use my professional judgment to determine
whether it is appropriate to disclose PHI to prevent harm.
If there is a child abuse investigation, I may be compelled to
turn over your relevant records.

Mentally Ill or
Developmentally Disabled Adults: If I have reasonable cause
to believe that a mentally ill or developmentally disabled adult,
who receives services from a community program or facility, has
been abused, I may be required to report the abuse. Additionally,
if I have reasonable cause to believe that any person with whom I
come into contact has abused a mentally ill or developmentally
disabled adult, I may be required to report the abuse. Regardless
of whether I am required to disclose PHI or to release documents,
I also have an ethical obligation to prevent harm to my patients
and others. I will use my professional judgment to determine
whether it is appropriate to disclose PHI to prevent harm.

Adult and Domestic
Abuse: If I have the responsibility for the care of an
incapacitated or vulnerable adult, I am required to disclose PHI
when I have a reasonable basis to believe that abuse or neglect
of the adult has occurred or that exploitation of the adult's
property has occurred.

Elder Abuse: If I
have reasonable cause to believe an elder with whom I have had
contact has been abused, I may be required to report the abuse.
Additionally, if I have reasonable cause to believe that an adult
with whom I have had contact has abused an elder, I may be
required to report the abuse.

Serious Threat to Health
or Safety: If you communicate to me an explicit threat of
imminent serious physical harm or death to a clearly identified
or identifiable victim(s) and I believe you have the intent and
ability to carry out such a threat, I may have a duty to take
reasonable precautions to prevent the harm from occurring,
including disclosing information to the potential victim and the
police and in order to initiate hospitalization procedures. If I
believe there is an imminent risk that you will inflict serious
harm on yourself, I may disclose information in order to protect
you. I must limit disclosure of the otherwise confidential
information to only those persons and only that content which
would be consistent with the standards of the profession in
addressing such problems.

Health Oversight:
When authorized by law, I may be required to disclose your PHI to
a health oversight agency for activities, such as audits,
investigations, inspections, licensure actions or other legal
proceedings. A health oversight agency is a state or
federal agency that oversees the health care system.

Judicial and
Administrative Proceedings: If you are involved in a court
proceeding and a request is made for information about the
professional services I provided you and/or the records thereof,
such information is privileged under state law, and I will not
release information without a court order or the written
authorization of you or your legally appointed representative.
The privilege does not apply when you are being evaluated for a
third party or where the evaluation is court-ordered. You will be
informed in advance if this is the case.

Worker's
Compensation: I may disclose PHI as authorized by and to the
extent necessary to comply with laws relating to worker's
compensation or other similar programs, established by law, that
provide benefits for work-related injuries or illness without
regard to fault.

Section 164.512 of the
Privacy Rule: This includes certain narrowly-defined
disclosures to law enforcement agencies, to a health oversight
agency (such as HHS or a state department of health), to a
coroner or medical examiner, for public health purposes relating
to disease or FDA-regulated products, or for specialized
government functions such as fitness for military duties,
eligibility for VA benefits, and national security and
intelligence.

IV. Patient's Rights and Psychologist's Duties

Patient's Rights:

Right to Request
Restrictions: You have the right to request restrictions on
certain uses and disclosures of certain PHI. However, I am not
required to agree to a restriction you request.

Right to Receive
Confidential Communications by Alternative Means and at
Alternative Locations: You have the right to request and
receive confidential communications of PHI by alternative means
and at alternative locations. (For example, you may not want a
family member to know that you are seeing me. Upon your request,
I will make alternative arrangements regarding billing.)

Right to Inspect and
Copy: You have the right to inspect or obtain a copy (or
both) of PHI and psychotherapy notes in my mental health and
billing records used to make decisions about you for as long as
the PHI is maintained in the record. I may deny your access to
PHI under certain circumstances, but in some cases, you may have
this decision reviewed. On your request, I will discuss with you
the details of the request and denial process.

Right to Amend: You
have the right to request an amendment of PHI for as long as the
PHI is maintained in the record. I may deny your request. On your
request, I will discuss with you the details of the amendment
process.

Right to an
Accounting: You generally have the right to receive an
accounting of disclosures of PHI for which you have neither
provided consent nor authorization (as described in Section III
of this Notice). On your request, I will discuss with you the
details of the accounting process.

Right to a Paper
Copy: You have the right to obtain a paper copy of the notice
from me upon request, even if you have agreed to receive the
notice electronically.

Right to Restrict
Disclosures When You Have Paid for Your Care Out-of Pocket:
You have the right to restrict certain disclosures of PHI to a
health plan when you pay out-of-pocket in full for my services.

Right to Be Notified if
There is a Breach of Unsecured PHI: You have a right to be
notified if: (a) there is a breach (a use or disclosure of your
PHI in violation of the HIPPA Privacy Rule) involving your PHI;
(b) that PHI has not been encrypted to government standards; and
(c) my risk assessment fails to determine that there is a low
probability that your PHI has been compromised.

Psychologist's Duties:

I am required by law to
maintain the privacy of PHI and to provide you with a notice of
my legal duties and privacy practices with respect to PHI.

I reserve the right to
change the privacy policies and practices described in this
notice. Unless I notify you of such changes, however, I am
required to abide by the terms currently in effect.

If I revise my policies and
procedures during your course of treatment or evaluation, I will
notify you by mail.

V. Questions and Complaints

If you are concerned that I have violated your privacy rights,
have questions or you disagree with a decision I made about
access to your records, please contact me first. However,
if you are still not satisfied with our resolution, may also send
a written complaint to: Office of the Secretary, U.S. Department
of Health and Human Services, 200 Independence Avenue, S.W.,
Washington, D.C. 20201. You will not be penalized in any way for
filing a complaint.

VI. Effective Date, Restrictions and Changes to Privacy
Policy

This notice is in effect as of August 1, 2017.

I will limit the uses or disclosures to the extent that such
limitation does not affect my right to make a use or disclosure
that is required by law or, when in good faith, to use or
disclose to avert a serious threat to health or safety of a
person or the public and such use or disclosure is made to a
person or persons reasonably able to prevent or lessen the threat
(including the target of the threat).

I reserve the right to change the terms of this notice and to
make the new notice provisions effective for all PHI that I
maintain. If changes are made, I will provide you with a revised
notice.

Electronic Signature of Client or Legal Guardian( Type Full Name )I have read and I agree to the Notice of Privacy Practices

Consent For Treatment

I have received and reviewed all information contained in the
Policies and Service Agreement.

I hereby acknowledge that I have been offered a copy of the
Notice of Privacy Practices (Notice of Psychologists'
Policies and Practices to Protect the Privacy of Your Health
Information).

I understand the limits to confidentiality required by law.

I accept financial responsibility for payment of all fees at the
time of service, unless other arrangements have been made. I
hereby authorize the release of all information necessary to
secure the payment of benefits as well as the use of my signature
on all insurance submissions. I herby authorize the payment of
insurance benefits from my insurance company to Dr. Hediger.
Furthermore, I understand that I am financially responsible for
all charges that are denied by the insurance company, as well as
for any deductible and/or co-payments.

I consent to having treatment services provided by Dr. Hediger
including, psychological evaluation, treatment, and diagnostic
procedures that are deemed advisable during the course of my
treatment.

I have been informed about the potential risks and benefits of
therapy.

I understand that maximum benefit will occur with consistent
attendance and that I may, at times, feel conflicted about my
therapy, as the process can sometimes be uncomfortable.

I understand that there is an expectation that I will benefit
from psychotherapy, but there is no guarantee this will occur.

In the event that the identified client is a minor, I affirm that
I am their legal guardian with the authority to authorize mental
health services for them.

I understand that my questions about the process and progress of
treatment are encouraged and always welcome. I understand that I
have the right to stop therapy whenever I wish or to seek
services elsewhere (including the right to ask for and receive
referral resources).

I understand that I must inform Dr. Hediger of all cancelations
at least 24 hours before the time of the appointment. If I fail
to cancel and do not show up, I may be charged $50 for that
appointment, not payable by insurance

I have read, understand, and agree to the above stated rules and
conditions for treatment.

Electronic Signature of Client or Legal Guardian( Type Full Name )I have read and I agree to the Consent For Treatment